The Potential for Improving the Diagnostics of Nosocomial Meningitis and Ventriculitis

The aim of the study was to identify the most specific and sensitive criteria for diagnosing nosocomial meningitis and ventriculitis.

Materials and methods. A retrospective case-control cohort study conducted at the department of anesthesiology and intensive care of the A. L. Polenov Russian Research Neurosurgical Institute (RRNI), a branch of the V. A. Almazov National Medical Research Center (NMRC) of the Ministry of Health of Russia included 120 patients who underwent intracranial neurosurgery: the main group (N=60) — patients with nosocomial meningitis (NM), and the comparison group (N=60) — patients without NM. Inclusion criteria: age over 18 years. Exclusion criteria: severe immunosuppressive condition (HIV infection), signs of central nervous system (CNS) infection (meningitis, ventriculitis, brain abscess) on admission, extracranial surgical interventions, pre-operative cerebrospinal fluid leakage, CNS trauma, and extracranial causes of CNS infection. The US Centers for Disease Control and Prevention (CDC) and the Burdenko National Medical Research Center for Neurosurgery criteria for NM diagnosis were used in the study.

Results. External validation of the NM diagnostic criteria in the analyzed patient cohort resulted in 81.67% sensitivity and 83.33% specificity of the CDC criteria. Sensitivity and specificity of the Burdenko National Medical Research Center for Neurosurgery criteria were 81.67% and 88.33%, respectively, for probable NM, and 51.67% and 100%, for confirmed NM. The CDC criteria demonstrated the highest sensitivity for protein concentration in cerebrospinal fluid (CSF) > 0.33 g/L (83.6%), with simultaneous extremely low specificity of 21%, and the highest specificity for the CSF positive culture (100%). As for the Burdenko National Research Medical Center for Neurosurgery criteria, in probable NM the highest sensitivity was established for CSF cell count > 65 cells/µL (64.4%), and the highest specificity — for CSF glucose < 2.6 mmol/l (93.9%) and CSF/serum glucose ratio (CSF/SGLU) < 0.45 (96.8%). In confirmed NM, CSF cell count > 65 cells/µL was also the most sensitive parameter (95.2%), although with 51% specificity. The highest specificity was found for the CSF lactate >

4.2 mmol/L (92.3%). The optimal threshold values were calculated for four parameters: body temperature

> 37.7°C, CSF cell count > 245 cells/µL, CSF glucose < 2.0 mmol/L, and CSF lactate > 3.7 mmol/L. Using a combination of threshold values for all four parameters, we achieved a sensitivity of 90.00% and a specificity of 91.67%. CSF cell count (AUC=0.90; 95% CI 0.84–0.95), increased CSF lactate (AUC=0.85; 95% CI 0.75–0.93), total CSF protein (AUC=0.83; 95% CI 0.75–0.90) and body temperature (AUC=0.82; 95% CI 0.74–0.89) had the greatest diagnostic value. Positive CSF culture and the occipital muscle rigidity correlated with the diagnosis of NM (rbp=0.522 and rbp=0.415, respectively, P=0.0001), but did not show good predictive diagnostic capacity.

Conclusion. Fever, increase in CSF cell count and CSF lactate were identified as the most clinically significant signs of NM. A positive CF culture traditionally used as the gold standard for diagnosis of NM showed low sensitivity of 69.2%. When taken together, the identified in the study threshold values of body temperature, CSF cell count, CSF glucose and lactate have a higher sensitivity and specificity than those used earlier.

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